Wyoming-Licensed PA Emergency Supervision Form
Emergency Physician Assistant Supervising Form
Wyoming-Licensed Physician Assistant Name *
Your answer
Wyoming Physician Assistant License Number *
Your answer
Wyoming Physician Assistant Cell Phone *
Your answer
Wyoming Physician Assistant Email *
Your answer
Location of Practice/Patient Care *
Your answer
General Description of Patient Care to be Provided *
Your answer
Description of Emergency *
Wyoming-Licensed Supervising Physician Name *
Your answer
Wyoming-Licensed Supervising Physician License Number *
Your answer
Wyoming-Licensed Supervising Physician Cell Phone *
Your answer
Wyoming-Licensed Supervising Physician Email *
Your answer
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